PathophysiologyNormal Spinal CordSpinal cord begins at the foramen magnum in the craniumCord ends at the L1-L2 vertebra levelSpinal nerves continue to the last sacral vertebraThe Human Spine

Spinal CordGray matter- cell bodies of voluntary and autonomic motor neurons

White matter axons of ascending and descending motor fibers

Normal Spinal CordWhite tracts send messages to and from the brainAscending Tracts- carry into higher levels of CNS touch, deep pressure,vibration, position, temperatureDescending Tractsimpulses for voluntary muscle movement

Pyramidal-Voluntary movementsPosterior column (Dorsal)- touch, proprioception, and vibration senseLateral spinothalamic tract- pain and temperature sensation (only tract that crosses within the cord)voluntary movement

Upper Motor NeuronsUMN Originate in cerebral cortexProject downwardResult in skeletal muscle movementInjury = SPASTIC paralysis

Lower Motor NeuronsLMNOriginate at each vertebral levelProject to specific parts of the bodyResult in movement /sensationInjury = FLACCID paralysis

Normal Spinal CordReflex Arc Involuntary response to a stimulus

Where sensory and motor nerves arise from cordSensory fibers enter posteriorSynapse in the grey matterMotor fibers leave anterior Once outside cord join form spinal nerve

reflex movement

Normal Spinal Cord DermatonesSkin innervated by sensory spinal nervesMyotome- muscle group innervated by motor neurons

Nervous System and the Spinal CordANS can be affected by SCISympathetic chains on both sides of the spinal column (T1-L2)Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4)

Spinal Cord ProtectionBones- vertebral column7 Cervical12 Thoracic5- Lumbar5- Sacral

Discs- between vertebra

Spinal Cord ProtectionInternal and external ligamentsDuraMeningesCSF in subarachnoid space allow for movement within spinal canal

Etiology of Traumatic SCIMVA- most common causeOther: falls, violence, sport injuriesSCI typically occurs from indirect injury from vertebral bones compressing cord SCI frequently occur with head injuriesCord injury may be caused by direct trauma from knives, bullets, etc

Etiology of Traumatic SCI78% people with SCI are maleTypically young men 16-30Number of older adults rising (>61 yr)Greater complicationsLife Expectancy 5 years less than same age without injury90% go home

Spinal Cord Injury- SCICompressionInterruption of blood supplyTractionPenetrating Trauma

Spinal Cord InjuryPrimaryInitial mechanism of injurySecondaryOngoing progressive damageIschemiaHypoxiaMicrohemorrhageEdema

Spinal Cord InjuryHemorrhage and edema occur in the cord post injury, causing more damage to cord

Extension of the cord injury from cord edema can occur over the first few dayswatch the phrenic nerve!

Initially SCI experience spinal shock depression of all cord & ANS function below injury. Lasts from few min to wks

Spinal and Neurogenic ShockSpinal ShockDecreased reflexes and loss of sensation below the level of injuryMotor loss- flaccid paralysis below level injurySensory loss- loss touch, pressure, temperature pain and proprioception perception below injuryLasts days to months

Spinal and Neurogenic ShockNeurogenic shockDue to loss of vasomotor toneSNS loss results in parasympathetic dominance with vasomotor failureLoss of SNS innervation causes peripheral pooling and decreased cardiac output Hypotension and Bradycardia Orthostatic hypotension and poor temperature control (poikilothermic)

How do you know spinal shock is over?

Clonus is one of the first signs Hyperreflexia of footTest by flexing leg at knee & quickly dorsiflex the footRhythmic oscillations of foot against handclonus

Classifications of SCIMechanism of InjurySkeletal and Neurologic LevelCompleteness (degree) of Injury

Mechanism of InjuryFlexionHyperextension CompressionFlexion /Rotation

Classifications of SCIMechanism of Injury

Flexion (hyperflexion)Most common because of natural protection position. Generally cause neck to be unstable because stretching of ligaments

Classifications of SCIMechanism of Injury

HyperextentionCaused by chin hitting a surface area, such as dashboard or bathtubUsually causes central cord syndrome symptoms

Classifications of SCIMechanism of Injury

CompressionCaused by force from above, as hit on headOr from below as landing on buttUsually affects the lumbar region

Classifications of SCIMechanism of Injury

Flexion/RoatationMost unstableResults in tearing of ligamentous structures that normally stabilize the spineUsually results in serious neurologic deficits

Skeletal levelVertebral level where the most damage to the bonesNeurologic levelThe lowest segment of the spinal cord with normal sensory and motor function on both sides of the body

Levels of Function in Spinal Cord Injury

Classification of SCI- Level of InjurySpinal cord levelWhen referring to spinal cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level.

the thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone

Classifications of SCICompleteness (Degree) of Injury

CompleteIncompleteCentral cord syndromeAnterior Cord syndromeBrown-Sequard SyndromePosterior Cord SyndromeCauda Equina and Conus Medullaris

Classification of SCI Completeness (degree) of InjuryComplete (transection)After spinal shock: Motor deficits- spastic paralysis below level of injurySensory- loss of all sensation perceptionAutonomic deficits- vasomotor failure and spastic bladder

Classification of SCI Completeness (degree) of InjuryIncompleteCentral Cord Syndrome

Injury to the center of the cord by edema and hemorrhageMotor weakness and sensory loss in all extremities Upper extremities affected more

Classification of SCI Completeness (degree) of InjuryIncomplete Brown-Squard Syndrome

Hemisection of cordIpsilateral paralysisIpsilateral superficial sensation, vibration and proprioception lossContralateral loss of pain and temperature perception

Classification of SCI Completeness (degree) of InjuryincompleteAnterior Cord Syndrome

Injury to anterior cord Loss of voluntary motor, pain and temperature perception below injuryRetains posterior column function (sensations of touch, position, vibration, motion)

Classification of SCI Completeness (degree) of InjuryincompletePosterior Cord Syndrome

Least frequent syndromeInjury to the posterior (dorsal) columns Loss of proprioceptionPain, temperature, sensation and motor function below the level of the lesion remain intact

Classification of SCI Completeness (degree) of InjuryincompleteConus MedullarisInjury to the sacral cord (conus) and lumbar nerve rootsCauda EquinaInjury to the lumbosacral nerve roots Result- areflexic (flaccid)bladder and bowel, flaccid lower limbs

Clinical Manifestations of SCISkin: pressure ulcers

Neuro: pain sensory lossupper/lower motor deficitsautonomic dysreflexia

Cardio: dysrhythmiasspinal shockloss of SNS control over blood vesselsorthostatic hypotension, poikilothermic

Respiratory-decrease chest expansion, cough reflex & vital capacitydiaphragm function-phrenic nerve GIstress ulcersparalytic ileusbowel- impaction & incontinence

GUupper/lower motor bladderImpotencesexual dysfunctionMusculoskeletaljoint contracturesbone demineralizationosteoporosismuscle spasmsmuscle atrophypathologic fracturespara/tetraplegia

Common Manifestation/ComplicationsUpper and Lower Motor Deficits

Upper motor deficits result in spastic paralysis

Lower motor deficits result in flaccid paralysis and muscle atrophy

Common Manifestations/ComplicationsSpinal cord injuries are described by the level of the injury the cord segment or dermatome levelSuch as C6; L4 spinal cord injury

Terms used to describe motor deficitsPrefix: para- meaning two extremitiestetra- or quadra- all four extremitiesSuffix :-paresis meaning weakness -plegia meaning paralysis

Quadraparesis means what?

Common Manifestations/ComplicationsC1-3 usually fatal- Loss of phrenic innervation ventilator dependent No B/B controlSpastic paralysisElectric w/c with chin/mouth control

Common Manifestations/ComplicationsC6- weak graspHas shoulder/biceps to transfer & push w/cNo bowel/bladder control.

Considered level of independence

Common Manifestations/ComplicationsT1-6- full use of upper extremityTransferDrive car with hand controls and do ADLsNo bowel/bladder control

Immediate CareEmergency Care at Scene, ER & ICU

Transport with cervical collarAssess ABCs; O2; tracheotomy/ventIV for life lineNG to suctionFoley

Diagnostic Studies for SCI

X-ray of spinal columnCT/MRIBlood gases

Therapeutic Interventions MedicationsIV methylprednisolone (Solu-Medrol) within 8 hrs to decrease cord edema

Therapeutic InterventionsMedications To control or to prevent complications of SCI and immobility:Vasopressors to maintain perfusionHistamine H2 blockers to prevent stress ulcersAnticoagulantsStool softenersAntispasmodics

Therapeutic InterventionsStabilization/Immobilization

Traction-Gardner-wells tongsHalo

CastsSplintsCollarsBraces

Therapeutic InterventionsSurgery for SCI

Manipulation to correct dislocation or to unlock vertebraeDecompression laminectomySpinal fusionWiring or rods to hold vertebrae together

Nursing Management AssessmentHEALTH HISTOYDescription of how and when injury occurredOther illnesses or disease processesAbility to move, breathe, and associated injury such as a head injury, fractures

Nursing Management AssessmentPHYSICAL EXAM

LOC and pupils- may have indirect SCI from head injuryRespiratory status- phrenic nerve (diaphragm) and intercostals; lung soundsVital signsMotorSensoryBowel and bladder function

Nursing ManagementAssessmentMotor Assessment Upper Extremity

Movement, strength and symmetry

Hand grips

Flex and extend arm at elbow- with and without resistance

Nursing Management Assessment Motor Assessment Lower Extremity

Flex and extend leg at knee with and without resistancePlanter and dorsi flexion of footAssess for Clonus

Nursing Management AssessmentSensory assessment

With the sharp and dull ends of a paperclip have the individual, with their eyes closed identify

Use the dermatome as reference to identify level

C6 thumb; T4 nipple; T10 naval

Nursing Problems/Interventions

1.Impaired mobility2.Impaired gas exchange3. Impaired skin integrity4. Constipation5. Impaired urinary elimination6. Risk for autonomic dysreflexia7. Ineffective coping

1. Impaired Physical MobilityLog roll as a single unit; provide assistance as needed to keep alignment; teach patient Care traction, collars, splints, braces, assistive devices for ADLsFlaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)

1. Impaired Physical MobilitySpastic ParalysisPrevent spasms by avoiding; sudden movements or jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigueTreat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmodic medications Assess skin break down thrombophlebitis; remove TED hose at least every shift

1. Impaired Physical MobilityPrevent/treat orthostatic hypotension Abdominal binder, calf compressors, TED hose when individual gets upAssess BP, especially when rising

Teach use of transfer boardAssist Physical Therapy with tilt table as individual gradually gets use to being in an upright position

2. Impaired Gas ExchangePhrenic nerve (C3-5) controls the diaphragm bilaterally. If nerve is nonfunctioning then individual is ventilator dependent.Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing

2. Impaired Gas ExchangeRespiratory rate, rhythm, depth, breath sounds, respiratory effort, ABGs, O2 saturation

Signs of impending extension of SCI up cord to phrenic nerve level (C3-5)Need for ventilatory assistance tracheotomy, ventilator

Quad cough (assistive cough) as needed

3. Impaired Skin IntegrityChange position frequentlyProtection from extremes in temperatureInspect skin at least 2x/day especially over boney prominences Avoid shearing and friction to soft tissue with transfersRemoval of TED hose every 8 hoursNutritional status

4. Constipation

Bowels rely more on bulk than on nervesStimulate bowels at the same time each day. Best after a meal when normal peristalsis occursIndividual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation Assess bowel sounds prior to giving food for the first time paralytic ileus!

5. Impaired Urinary Elimination

Flaccid bladder (lower motor neuron lesion) No reflex from S2,3,4Automatic empting of bladder Urine fills the bladder and dribbles outNeed Foley or freq intermittent self catheterization

Spastic bladder (upper motor neuron lesion) Reflex arc but no connection to or from brain Reflex fires at will Bladder training- trigger points to stimulate empting; self catheterization

5. Impaired Urinary EliminationUse bladder scan to see amount of urine in bladder Goal- residual

6. Risk for Autonomic DysreflexiaSCI above T6 Results in loss of normal compensatory mechanisms when sympathetic nervous system is stimulatedLife threatening- if goes unchecked BP can result in cerebral hemorrhage

Vasodilatation symptoms above SCIVasoconstriction symptoms below SCIThe cause of SNS stimulation

6. Risk for Autonomic Dysreflexia

Elevate head of bed- causes orthostatic hypotension Identify cause/alleviate- if full bladder- cath; if skin- remove pressure, if full bowel- empty, etcRemove support hose/abdominal binderMonitor blood pressure- can get > 300 SGive PRN medication to lower BPIf above not effective call physician

7. Ineffective Coping/Grief and Depression

Assess thoughts on quality of life; body image; role changesPhysical and psychological supportMost common SCI is 15-30 yeas old and generally a risk taker this greatly affects their perception of life and rehabilitation

7. Ineffective Coping/sexualityMaleFemaleUMN lesionreflexogenic (S2,3,4) erectionsLMN lesion psychogenic erections (psychological stimulation)

Ejaculation/fertility may be affectedhormones more than nerves regarding fertility. C-section because of chance for autonomic dysreflexia during labor. Lack of sensation/movement affects sexual performance

7. Ineffective Coping/sexualityAssess readiness/knowledge/your abilityUse proper terminologySuggestions: empty bladder before sexwithhold fluids and antispasmodicscertain positions may increase spasmsexplore new erogenous zonespenile implantsRefer to specially trained counselor

Home CareAssess psychological, physiological resourcesneed for rehabilitation (in-house or out patient)need for community resources

Home assessment

Whats new in SCI treatment?Superman breatherYouTube - Superman breather USA

Kevin Everetthypothermia treatment for SCIStanding TallTravis Roy- 11 Seconds

Stem Cell treatment for SCILipitor for SCI

Case study- Jim Valdez1. Why does Jim have flaccid paralysis on admission to ICU?2. What symptoms indicate that he is in spinal shock? What was done about these symptoms?3. How will we know when he is out of spinal shock?4. How does progressive mobilization assist with orthostatic hypotension? What else can be done?5. What are realistic functional goals for Jim?

Spinal Cord AnatomyFunction of disc is to allow for mobility of the spine and act as shock absorberspinal cord anatomy

Pathophysiology/Etiology Located between vertebral bodiesComposed of nucleus pulposus a gelatinous material surrounded by annulus fibrosis- a fibrous coilSpinal nerves come out between vertebra

Herniated DiscHerniated nucleus pulposus, (HNP) slipped disc, ruptured discHNP- annulus becomes weakened/torn and the nucleus pulposus herniates through it.Risk Factors-Standing erectAging changesPoor body mechanicsOverweightTrauma

Common Manifestations/ComplicationsHNP compressesSpinal nerve (sensory or motor component) as it leaves the spinal cordOr the cord itself- the white tracts within the cord- rare

Common Manifestations/ComplicationsSensory root or nerve usually affected pain, parenthesis, or loss of sensationMotor root or nerve may be affected paresis or paralysis

Manifestations depend on what nerve root, spinal nerve is being compressed which dermatomesRadiculopathy- pathology of the nerve root

Common Manifestations/Complications Lumbar HNPMost common site for HNPL4-5 disc- the 5th lumbar nerve rootposterior sensory nerve or root compressed

Classic symptoms- low back sciatica painpain increases with increase in intrathoracic pressure

herniated disc L4-L5

Other Symptoms Lumbar HNP:Postural changesUrinary/male sexual function changesParesis or paralysisFoot dropParesthesiasNumbnessMuscle spasmsAbsent cord reflexes

Common Manifestations/Complications Cervical HNPC5-C6 disc- affects the 6th cervical nerve root

Pain- neck, shoulder, anterior upper arm to thumbAbsent/diminished reflexes to the armMotor changes- paresis or paralysisSensory- paresthesias or painMuscle spasms

Therapeutic Interventions- Diagnostic TestsX-ray identify deformities and narrowing of disk spaceCT/MRIMylogram p1336Nerve conduction studies (EMG) detect electrical activity of skeletal muscles

Treatment- ConservativeBed rest with firm mattress log roll side lying position with knees bent and pillow between legs to support legsAvoid flexion of the spine brace/corset, cervical collar to provide supportMedicationsnon-narcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers

Treatment- ConservativeHeat/cold therapy to decrease muscle spasmsBreak the pain-spasm-pain cycleUltrasound, massage, relaxation techniquesProgressive mobilization with approved exercise program includes abdominal/thigh strengtheningTeaching good body mechanicsWeight lossTENS unit

Treatment- SurgeryLaminectomy- removal of a portion of the lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding outherniated disc repairForaminotomy Enlargement of the bony overgrowth at the opening which is compressing the nerve

Treatment- Surgery

Microdiskectomy Use of electron microscope through a small incision to remove a portion of the HNP that is displaced

If cervical HNP, usually use the anterior approach in the neckanterior cervical fusion

Treatment- SurgerySpinal fusion removes most of the disc and replaces it with bone usually from the patient iliac crestFusion also with rods, pins, synthetic proteinFlexibility is lost at the site- requires longer hospital stayspinal fusionArtificial DiscCombination of metal and plasticAttached to vertebrae above and below

Prevention of HNPBack school approach-Causes of HNPLearn how to prevent Good body mechanicsExercises to strengthen leg and abdominal muscles

Change in life-style or occupation

Nursing Assessment Specific to HNP Health HistoryAssess for risk factors- The cumulative effect of standing erect and daily stress Aging changes in disc/ligaments Poor body mechanics OverweightTraumaEmployment History of pain and other neuro changes

Nursing Assessment Specific to HNP Physical Exam Use similar methods to assess as utilized SCI

Muscle strength and coordinationSensationsharp/dull of paperclip using dermatome as referencePain evaluation- pain scalePre/Post-op assessment

Post-Op Assessment for HNP

Sensory/motor assessment- care not to injure op siteAssess for CSF drainage or bleeding from op siteEncourage turn (log roll, cough, deep breath) Assess for postural hypotensionespecially if client was on bed rest for several days/weeks prior to surgery

Post-op Assessment for HNPIf Anterior Cervical- Assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness)Assess respiration, neck size, swallowing and speech

If Post-Op Lumbar- Assess bowels sounds, voiding. Minimize stress of post-op site- flat with pillow between knees, log roll, etc

Nursing Problems/Interventions 1. Acute PainPost surgery the individual may have similar pain as pre-op due to lack of resiliency of the spinal nerves to bounce back quickly

Donor site (illiac crest) may cause more pain than laminectomy

Individual may be in a pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic

2. Chronic PainSurgery may not relieve pain

Nonpharmalogical methods to control pain

Pain clinic

3. ConstipationAs a result of bed rest and decreased mobility and fear of pain with straining of stool

Constipation prevention methods fluids, diet, etc

4. Home CareWhen riding in a car, take frequent stops to move and stretchPrevention Back school approachMay have to deal with pain as a chronic conditionMay need to make life/job changes

Spinal Cord TumorsCNS is made up of neural tissue and support tissue

These tissues undergo changes and result in spinal cord tumors

Blood vessels and bone also can be part of the tumor

Intramedullary- arise from neural tissues of the spinal cord

Extramedullary- arise from tissues outside the spinal cord may be benign or malignantIntradural-from the nerve roots or meninges in subarachnoid spaceExtradural- from the epidural tissue or vertebra

Classification by originPrimary- originating in the spinal cord or meninges

Secondary- metastases from other parts of the bodyMost spinal cord tumors are found in the thoracic region

Spinal cord tumors can compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction

Common Manifestations/ComplicationsSymptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected

Pain that is not relieved by bed rest is the most common presenting symptom

Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor

Common Manifestations/ComplicationsManifestations of thoracic cord tumorParesis & spasticity of one leg then the otherPain back & chest, not relieved by bedrest Sensory changes Babinski reflexBowel (ileus); bladder dysfunction (UMN in type)

Therapeutic Interventions

Diagnostic tests include:X-ray of the spinal columnMyelogramLumbar puncture with CSF analysis

Therapeutic InterventionsMedications spinal tumorsControl pain- narcotic analgesics, epidural catheter, PCA, NSAIDs

Reduce cord edema and tumor size- Steroids- high dose Dexamethasone

Therapeutic InterventionsSurgery for spinal cord tumorsLaminectomy to remove or to decrease the size (decompression laminectomy) of the spinal cord tumorSpinal fusion or the insertion of rods if several vertebra involved and the column is unstable

Radiation to reduce size and control pain

Nursing AssessmentHealth historyPain, motor and sensory changes, bowel and bladder changes, Babinski reflex.

Physical examSimilar to physical assessment for HNP

Nursing Problems/Interventions1. AnxietyMetatastic tumor vs benign spinal cord tumorEducation and support system

2. Risk for constipationFrom spinal cord compression, narcotics, bed restAdjust fluid and diet

Nursing Problems/Interventions3. Impaired physical mobilityFrom bed rest and motor involvementBasic nursing- ROM, etc 4. Acute painFrom compression or invasion of tumorAssess and treat

5. Sexual dysfunctionMale sacral reflex arc (S 2,3,4) interferenceSimilar care as discussed with SCI

Nursing Problems/Interventions6. Urinary retentionReflex arc (S2,3,4) interference can cause neurogenic bladder as discussed with SCI

7. Home careRehabilitationHome evaluationSupport groupscase study

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?

Bladder distensionNeurological deficitPulse ox readingsThe clients feelings about the injury

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?

Autonomic dysreflexiaHemorrhagic shockNeurogenic shockPulmonary embolism

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

Place the client flat in bedAssess patency of the indwelling urinary catheterGive one SL nitroglycerin tabletRaise the head of the bed immediately to 90 degrees

The nurse is caring for an elderly client diagnosed with a herniated nucleus pulposus of L4-L5. Which scientific rationale explains the incidence of a ruptured disc in the elderly?The client did not use good body mechanics when lifting an object.There is an increased blood supply to the back as the body ages.Older clients develop atherosclerotic joint disease as a result of fat deposits.Clients develop intervertebral disc degeneration as they age.

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?Acetazolamide (Diamox)Furosemide (Lasix)Methylprednisolone (Solu-Medrol)Sodium bicarbonate

A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?

To hasten wound healingTo immobilize the surgical spineTo prevent autonomic dysreflexiaTo hold bony fragments of the skull together

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?Insert an indwelling urinary catheter to straight drainageSchedule intermittent catherization every 2 to 4 hoursPerform a straight catherization every 8 hours while awakePerform Credes maneuver to the lower abdomen before the client voids.

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?

Absent corneal reflexDecerebate posturingMovement of only the right or left half of the bodyThe need for mechanical ventilation

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?

Positive reflexesHyperreflexiaInability to elicit a Babinskis reflexReflex emptying of the bladder

Your T1 spinal cord injured patient complains of a headache. You should

Give him prn TylenolDisimpact his bowelsCall the doctorTake his blood pressure

What can the nurse do to best speed the patients recovery from a laminectomy of L5?

Keep patient flat in bedTeach the back school approachMedicate for pain q2 hoursAmbulate as soon as orders permit

Your patient has a malignant metastatic lesion at T8 and is in for palliative radiation. What is your main goal with this patient?

Teach patient self catheterizationEnsure patient receives pain medication as neededEncourage patient to discuss fearsAmbulate twice a shift

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